A 54-year-old male active smoker with diabetes, hypertension, and history of coronary artery disease was referred to you for routine evaluation and to establish care after relocating. He reports he has been feeling well and has been active with no exertional limitations. His medical records demonstrate history of a percutaneous coronary intervention (PCI) 6 months ago after having an abnormal stress test following referral for evaluation of recurrent angina. Your patient states he has been chest-pain free since revascularization. The angiogram is not available to you for review, but the medical records include a copy of the procedure report. Review of the cardiac catheterization report shows rotational atherectomy was performed followed by implantation of a 3.0 x 38 mm drug-eluting stent (DES) in the proximal left anterior descending (LAD) artery. In addition to guideline-directed medical therapy, he has been taking dual antiplatelet therapy (DAPT) since his procedure with no issues. Your patient reports that his DAPT regimen includes aspirin 81 mg once daily and ticagrelor 90 mg twice daily.
After discussing with your patient the risks and benefits of DAPT including bleeding and ischemic risk, which of the following would you recommend as the best course of action for his antiplatelet regimen at this time?
Show Answer
The correct answer is: B. Continue current DAPT regimen
This patient underwent PCI in the setting of stable ischemic heart disease (SIHD). The procedure included rotational atherectomy, indicating the likelihood of the presence of a calcified coronary lesion. Stent implantation involved a long stent (length ≥30 mm). Lesion complexity can impact the risk of ischemic events particularly within the first year following PCI, and presence of increased lesion complexity favors prolonged DAPT.1,2 Additionally, adjunctive intravascular imaging was not used during the PCI, and selection of a 3.0 mm diameter stent in a calcified proximal LAD segment may increase the likelihood for stent underexpansion or undersizing.
This patient has tolerated DAPT with no bleeding issues. He has both clinical factors and procedural factors from his PCI that increase his risk for ischemic events. Weighing his risk for bleeding with the benefit of reducing his risk for ischemic events, this patient would benefit from continuing his DAPT regimen at this time given that his PCI was 6 months ago.
Based on the current guidelines, for patients with SIHD treated with DES implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, or oral anticoagulant use), continuation of DAPT longer than 6 months may be reasonable (Class IIb, level of evidence A).3 In patients treated with DAPT, a daily aspirin dose of 81 mg (range 75-100 mg) is recommended (Class I, level of evidence B).3
References
Yeh RW, Kereiakes DJ, Steg PG, et al. Lesion Complexity and Outcomes of Extended Dual Antiplatelet Therapy After Percutaneous Coronary Intervention. J Am Coll Cardiol 2017;70:2213-23.
Palmerini T, Stone GW. Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: conceptual evolution based on emerging evidence. Eur Heart J 2016;37:353-64.
Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation 2016;134:e123-55.
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